|
digoxin 125 mcg (0.125 mg) Tab [CQCH]
|
Facility
|
OP
|
$1.23
|
|
|
Service Code
|
NDC 904592161
|
| Hospital Charge Code |
105918974
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$1.11 |
| Rate for Payer: Aetna of AZ Commercial |
$1.11
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.20
|
| Rate for Payer: Banner UC Health Medicare |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.20
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.98
|
| Rate for Payer: Cigna of AZ Commercial |
$0.80
|
| Rate for Payer: Devoted Health Medicare |
$0.22
|
| Rate for Payer: Humana of AZ Medicare |
$0.20
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.84
|
| Rate for Payer: TriWest Medicare |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.70
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.19
|
|
|
digoxin 500 mcg (0.25 mg/mL) Inj Sol [CQCH]
|
Facility
|
OP
|
$1.54
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
105918899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of AZ Commercial |
$1.39
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.25
|
| Rate for Payer: Banner UC Health Medicare |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1.05
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.25
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.25
|
| Rate for Payer: Cash Price |
$1.24
|
| Rate for Payer: Cigna of AZ Commercial |
$1.00
|
| Rate for Payer: Devoted Health Medicare |
$0.28
|
| Rate for Payer: Humana of AZ Medicare |
$0.25
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1.05
|
| Rate for Payer: TriWest Medicare |
$0.25
|
| Rate for Payer: United Healthcare Commercial |
$0.88
|
| Rate for Payer: United Healthcare Medicare |
$0.25
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.24
|
|
|
digoxin 500 mcg (0.25 mg/mL) Inj Sol [CQCH]
|
Facility
|
IP
|
$1.54
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
105918899
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.39 |
| Rate for Payer: Aetna of AZ Commercial |
$1.39
|
| Rate for Payer: Cash Price |
$1.24
|
|
|
Digoxin Level
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
633719
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.26 |
| Max. Negotiated Rate |
$165.60 |
| Rate for Payer: Aetna of AZ Commercial |
$165.60
|
| Rate for Payer: Aetna of AZ Commercial |
$241.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$42.88
|
| Rate for Payer: Arizona Complete Health Allwell |
$29.44
|
| Rate for Payer: Banner UC Health Medicare |
$42.88
|
| Rate for Payer: Banner UC Health Medicare |
$29.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$125.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$182.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$29.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$42.88
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$29.44
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$42.88
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Cash Price |
$147.20
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Cigna of AZ Commercial |
$174.20
|
| Rate for Payer: Cigna of AZ Commercial |
$119.60
|
| Rate for Payer: Devoted Health Medicare |
$48.24
|
| Rate for Payer: Devoted Health Medicare |
$33.12
|
| Rate for Payer: Humana of AZ Medicare |
$29.44
|
| Rate for Payer: Humana of AZ Medicare |
$42.88
|
| Rate for Payer: Seven Corners Travel Insurance |
$19.26
|
| Rate for Payer: Seven Corners Travel Insurance |
$19.26
|
| Rate for Payer: Southwest Service Administrators UFCW |
$182.24
|
| Rate for Payer: Southwest Service Administrators UFCW |
$125.12
|
| Rate for Payer: TriWest Medicare |
$29.44
|
| Rate for Payer: TriWest Medicare |
$42.88
|
| Rate for Payer: United Healthcare Commercial |
$105.25
|
| Rate for Payer: United Healthcare Commercial |
$153.30
|
| Rate for Payer: United Healthcare Medicare |
$29.44
|
| Rate for Payer: United Healthcare Medicare |
$42.88
|
| Rate for Payer: Veterans Affairs TRICARE |
$42.45
|
| Rate for Payer: Veterans Affairs TRICARE |
$29.15
|
|
|
Digoxin Level
|
Facility
|
IP
|
$268.00
|
|
|
Service Code
|
CPT 80162
|
| Hospital Charge Code |
633719
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$241.20 |
| Max. Negotiated Rate |
$241.20 |
| Rate for Payer: Aetna of AZ Commercial |
$241.20
|
| Rate for Payer: Aetna of AZ Commercial |
$165.60
|
| Rate for Payer: Cash Price |
$214.40
|
| Rate for Payer: Cash Price |
$147.20
|
|
|
Dihydrotestosterone LC
|
Facility
|
IP
|
$286.00
|
|
|
Service Code
|
CPT 80327
|
| Hospital Charge Code |
6781102
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$257.40 |
| Rate for Payer: Aetna of AZ Commercial |
$257.40
|
| Rate for Payer: Cash Price |
$228.80
|
|
|
Dihydrotestosterone LC
|
Facility
|
OP
|
$286.00
|
|
|
Service Code
|
CPT 80327
|
| Hospital Charge Code |
6781102
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.30 |
| Max. Negotiated Rate |
$257.40 |
| Rate for Payer: Aetna of AZ Commercial |
$257.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$45.76
|
| Rate for Payer: Banner UC Health Medicare |
$45.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$194.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$45.76
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$45.76
|
| Rate for Payer: Cash Price |
$228.80
|
| Rate for Payer: Cigna of AZ Commercial |
$185.90
|
| Rate for Payer: Devoted Health Medicare |
$51.48
|
| Rate for Payer: Humana of AZ Medicare |
$45.76
|
| Rate for Payer: Southwest Service Administrators UFCW |
$194.48
|
| Rate for Payer: TriWest Medicare |
$45.76
|
| Rate for Payer: United Healthcare Commercial |
$163.59
|
| Rate for Payer: United Healthcare Medicare |
$45.76
|
| Rate for Payer: Veterans Affairs TRICARE |
$45.30
|
|
|
DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)
|
Facility
|
OP
|
$5,008.71
|
|
|
Service Code
|
CPT 58120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$64.16 |
| Max. Negotiated Rate |
$5,008.71 |
| Rate for Payer: Banner UC Health Medicare |
$1,051.19
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$64.16
|
| Rate for Payer: Mercy Care Medicaid |
$64.16
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,051.19
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,008.71
|
| Rate for Payer: United Healthcare Commercial |
$4,169.00
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$25,133.27
|
|
|
Service Code
|
APR-DRG 5174
|
| Hospital Charge Code |
APRDRG5173
|
| Min. Negotiated Rate |
$25,133.27 |
| Max. Negotiated Rate |
$25,133.27 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$25,133.27
|
| Rate for Payer: Mercy Care Medicaid |
$25,133.27
|
| Rate for Payer: NaphCare Correctional Healthcare |
$25,133.27
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$25,133.27
|
|
|
Service Code
|
APR-DRG 5174
|
| Hospital Charge Code |
APRDRG5174
|
| Min. Negotiated Rate |
$25,133.27 |
| Max. Negotiated Rate |
$25,133.27 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$25,133.27
|
| Rate for Payer: Mercy Care Medicaid |
$25,133.27
|
| Rate for Payer: NaphCare Correctional Healthcare |
$25,133.27
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$5,973.12
|
|
|
Service Code
|
APR-DRG 5172
|
| Hospital Charge Code |
APRDRG5171
|
| Min. Negotiated Rate |
$5,973.12 |
| Max. Negotiated Rate |
$5,973.12 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,973.12
|
| Rate for Payer: Mercy Care Medicaid |
$5,973.12
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,973.12
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$4,712.71
|
|
|
Service Code
|
APR-DRG 5171
|
| Hospital Charge Code |
APRDRG5172
|
| Min. Negotiated Rate |
$4,712.71 |
| Max. Negotiated Rate |
$4,712.71 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,712.71
|
| Rate for Payer: Mercy Care Medicaid |
$4,712.71
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,712.71
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$25,133.27
|
|
|
Service Code
|
APR-DRG 5174
|
| Hospital Charge Code |
APRDRG5171
|
| Min. Negotiated Rate |
$25,133.27 |
| Max. Negotiated Rate |
$25,133.27 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$25,133.27
|
| Rate for Payer: Mercy Care Medicaid |
$25,133.27
|
| Rate for Payer: NaphCare Correctional Healthcare |
$25,133.27
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$10,337.23
|
|
|
Service Code
|
APR-DRG 5173
|
| Hospital Charge Code |
APRDRG5172
|
| Min. Negotiated Rate |
$10,337.23 |
| Max. Negotiated Rate |
$10,337.23 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,337.23
|
| Rate for Payer: Mercy Care Medicaid |
$10,337.23
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,337.23
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$5,973.12
|
|
|
Service Code
|
APR-DRG 5172
|
| Hospital Charge Code |
APRDRG5172
|
| Min. Negotiated Rate |
$5,973.12 |
| Max. Negotiated Rate |
$5,973.12 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,973.12
|
| Rate for Payer: Mercy Care Medicaid |
$5,973.12
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,973.12
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$4,712.71
|
|
|
Service Code
|
APR-DRG 5171
|
| Hospital Charge Code |
APRDRG5173
|
| Min. Negotiated Rate |
$4,712.71 |
| Max. Negotiated Rate |
$4,712.71 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,712.71
|
| Rate for Payer: Mercy Care Medicaid |
$4,712.71
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,712.71
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$4,712.71
|
|
|
Service Code
|
APR-DRG 5171
|
| Hospital Charge Code |
APRDRG5171
|
| Min. Negotiated Rate |
$4,712.71 |
| Max. Negotiated Rate |
$4,712.71 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,712.71
|
| Rate for Payer: Mercy Care Medicaid |
$4,712.71
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,712.71
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$10,337.23
|
|
|
Service Code
|
APR-DRG 5173
|
| Hospital Charge Code |
APRDRG5174
|
| Min. Negotiated Rate |
$10,337.23 |
| Max. Negotiated Rate |
$10,337.23 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,337.23
|
| Rate for Payer: Mercy Care Medicaid |
$10,337.23
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,337.23
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$4,712.71
|
|
|
Service Code
|
APR-DRG 5171
|
| Hospital Charge Code |
APRDRG5174
|
| Min. Negotiated Rate |
$4,712.71 |
| Max. Negotiated Rate |
$4,712.71 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,712.71
|
| Rate for Payer: Mercy Care Medicaid |
$4,712.71
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,712.71
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$10,337.23
|
|
|
Service Code
|
APR-DRG 5173
|
| Hospital Charge Code |
APRDRG5173
|
| Min. Negotiated Rate |
$10,337.23 |
| Max. Negotiated Rate |
$10,337.23 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,337.23
|
| Rate for Payer: Mercy Care Medicaid |
$10,337.23
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,337.23
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$25,133.27
|
|
|
Service Code
|
APR-DRG 5174
|
| Hospital Charge Code |
APRDRG5172
|
| Min. Negotiated Rate |
$25,133.27 |
| Max. Negotiated Rate |
$25,133.27 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$25,133.27
|
| Rate for Payer: Mercy Care Medicaid |
$25,133.27
|
| Rate for Payer: NaphCare Correctional Healthcare |
$25,133.27
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$10,337.23
|
|
|
Service Code
|
APR-DRG 5173
|
| Hospital Charge Code |
APRDRG5171
|
| Min. Negotiated Rate |
$10,337.23 |
| Max. Negotiated Rate |
$10,337.23 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$10,337.23
|
| Rate for Payer: Mercy Care Medicaid |
$10,337.23
|
| Rate for Payer: NaphCare Correctional Healthcare |
$10,337.23
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$5,973.12
|
|
|
Service Code
|
APR-DRG 5172
|
| Hospital Charge Code |
APRDRG5174
|
| Min. Negotiated Rate |
$5,973.12 |
| Max. Negotiated Rate |
$5,973.12 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,973.12
|
| Rate for Payer: Mercy Care Medicaid |
$5,973.12
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,973.12
|
|
|
Dilation And Curettage For Non-Obstetric Diagnoses
|
Facility
|
IP
|
$5,973.12
|
|
|
Service Code
|
APR-DRG 5172
|
| Hospital Charge Code |
APRDRG5173
|
| Min. Negotiated Rate |
$5,973.12 |
| Max. Negotiated Rate |
$5,973.12 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,973.12
|
| Rate for Payer: Mercy Care Medicaid |
$5,973.12
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,973.12
|
|
|
DILATION OF ESOPHAGUS TECH
|
Facility
|
OP
|
$406.00
|
|
|
Service Code
|
CPT 43450
|
| Hospital Charge Code |
28224519
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$64.31 |
| Max. Negotiated Rate |
$3,596.00 |
| Rate for Payer: Aetna of AZ Commercial |
$365.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$64.96
|
| Rate for Payer: Banner UC Health Medicare |
$343.75
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$276.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$109.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$64.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$64.96
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Cigna of AZ Commercial |
$284.20
|
| Rate for Payer: Devoted Health Medicare |
$73.08
|
| Rate for Payer: Humana of AZ Medicare |
$64.96
|
| Rate for Payer: Mercy Care Medicaid |
$109.48
|
| Rate for Payer: NaphCare Correctional Healthcare |
$343.75
|
| Rate for Payer: Seven Corners Travel Insurance |
$1,403.35
|
| Rate for Payer: Southwest Service Administrators UFCW |
$276.08
|
| Rate for Payer: TriWest Medicare |
$64.96
|
| Rate for Payer: United Healthcare Commercial |
$3,596.00
|
| Rate for Payer: United Healthcare Medicare |
$64.96
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$77.14
|
| Rate for Payer: Veterans Affairs TRICARE |
$64.31
|
|
